Patient-centered virtual reality (VR) programs could assist in the functional recovery of people after a stroke.
To analyze the feasibility of a rehabilitation protocol using client-centered VR and to evaluate changes in occupational performance and social participation.
This was a mixed methods study. Ten subacute and chronic stroke patients participated in the rehabilitation program using games in non-immersive VR for 40 minutes/day, three days/week, for 12 weeks. Sociodemographic information was collected and the outcome variables included were the Canadian Occupational Performance Measure (COPM) and the Participation Scale. A field diary was used to record the frequency of attendance and adherence of participants and an interview was conducted at the end of program.
There were significant and clinically-relevant statistical improvements in the COPM performance score (p < 0.001; CI = 1.29 − 4.858) and in the COPM satisfaction score (p < 0.001; CI = 1.37 − 5.124), with a difference greater than 4.28 points for performance and 4.58 points for satisfaction. The change in the scores for participation was statistically significant (p = 0.046), but there was no clinical improvement (dcohen = −0.596, CI = −1.862 − 0.671). The majority of participants reported more than 75% consecutive attendance of sessions and there was 100% adherence to the program. In the interviews, the participants described their post-stroke difficulties; how the video game motivated their engagement in rehabilitation; and the improvement of occupational performance and social participation after participating in the program.
VR is a viable tool for the rehabilitation of stroke patients with functional gains, mainly regarding occupational performance and performance satisfaction.
Every year, 16 million people suffer from a stroke, with great economic and social repercussions1. In Brazil, this is the leading cause of disability1,2. A stroke is a sudden syndrome, characterized by sensory, motor, and cognitive-perceptual alterations1. These alterations are associated with disability, limitations in activities of daily life (ADL) and restrictions in social participation, with loss of autonomy and independence3,4.
Different treatment protocols are used in post-stroke rehabilitation, and consist mainly of motor control approaches, and task oriented training5,6,7. Task-based training, mediated by technologies and computerized activities such as virtual reality (VR), has been promising for post-stroke patients8,9. Virtual reality is a technology for interaction between user and operating system using graphic resources that recreate a virtual environment10. One of its advantages is that the environment can be more interesting and pleasant when compared with traditional rehabilitation, increasing motivation, engagement and adherence of patients to the treatment10,11,12.
Recent clinical trials with post-stroke patients demonstrated the effectiveness of VR in the rehabilitation of dynamic balance13,14,15,16; motor function12,17,18,19,20,21; performance and independence in ADL12,14 and quality of life17,19,20,21. However, a systematic review found no significant difference in upper limb function when comparing VR with a conventional therapy8. Differences between groups were found only when VR was added to the usual treatments8. In another review, the VR effects varied from small to moderate for ADL and outcomes for social participation did not change with the intervention9.
Although systematic reviews and meta-analyses on VR effectiveness are growing, they were not conclusive regarding the protocol or intervention parameters, which makes the clinical use of VR difficult8,9,11. Higher frequencies of treatment are preferable; however, these findings were not statistically significant8,9. Personalized VR protocols that consider a specific patient’s requirements seem to offer more benefits. However, it should be noted that these results are also not conclusive and there is no consensus about the issue8,9.
As there is little consistency in the literature indicating better VR protocols to be used in clinical practice, it is fundamental to analyze the viability and the patient response potential regarding the intervention using VR. The studies with better quality methodologies evaluated outcomes related to the body structure and function8,9. To recommend the therapeutic use of VR in post-stroke patients it is essential to develop patient-centered interventions and focus on assessing performance-related outcomes in activity and participation.
A patient-centered practice is an approach that considers the person’s ability to deal with their health condition, to self-manage, to make decisions, to motivate themselves, and adhere to treatment7. In this context, this study aimed to analyze the feasibility of a rehabilitation protocol using patient-centered VR and to evaluate changes in occupational performance and social participation of patients after a stroke. The hypothesis was that VR would increase performance, reduce restrictions in participation, and be a viable tool for outpatient intervention with post-stroke patients.
This research was a feasibility study that used mixed methods, including a quantitative and qualitative approach. The quantitative study of the pre- and post-intervention type measured changes in occupational performance and social participation, after a rehabilitation program using VR. The feasibility of the VR was analyzed using qualitative methods. This study was approved by the Institution’s Research Ethics Committee.
Local and participants
The participants were recruited by convenience, at the Rehabilitation Center of the Clinical Hospital of the Federal University of Triângulo Mineiro (HC/UFTM), a public and free rehabilitation service with physical therapy, speech therapy, nutrition, nursing, psychology, and occupational therapy.
We selected participants with primary or recurrent stroke diagnoses, hemiparesis, age 18 or older, of either sex, who were in the rehabilitation program. We excluded participants with strokes older than five years, bilateral hemiparesis, and/or other diseases of the musculoskeletal and central nervous systems, wheelchair users, amputees, visually impaired patients, and those who could not understand or respond to the data collection instruments. The sample was selected from the medical records and by indication of the rehabilitation professionals. A total of 10 patients met the inclusion criteria and agreed to participate in the research.
Evaluation procedures and instruments
The procedures took place between January and August 2017 at the HC/UFTM Rehabilitation Center and was divided into three sequential phases.
Phase 1: Pre-intervention evaluation
The participants responded to a socio-demographic questionnaire and were evaluated according to self-reported occupational performance and social participation.
Occupational performance was measured by the Canadian Occupational Performance Measure (COPM). The patients selected the activities that they needed, but which they had not been able to perform, or were not satisfied with their performance23. The patients assigned a grade of 1-10 to the importance of each activity and selected the five with the most importance. Each activity selected was evaluated for the patient’s performance and satisfaction on a scale from 1-10. The total scores were calculated from the means of the performance and satisfaction. Changes in scores greater than two points indicated a clinically relevant improvement23.
Social participation was measured by the Participation Scale (P-Scale), version 6.0. The participants would compare themselves with a “peer without disability” and respond to how they perceived their own level of participation compared with the “peer”24. The score of any item varied from zero, when the individual did not have restrictions to his participation, to five when the restriction was considered a “big problem”. The total score varied from zero to 90, with smaller values indicating less restriction25.
Phase 2: Intervention
The rehabilitation program using VR was implemented at the HC/UFTM Rehabilitation Center. The literature does not have a standardization of interventions and/or games used in virtual reality programs. Thus, the protocol chosen had the number of sessions and duration following the findings of Aramaki et al26. Therefore, the protocol consisted of three weekly sessions lasting 40 minutes each, developed over 12 weeks, for a total of 36 sessions.
The participants were in an orthostatic position, four meters away from the screen and video game, in a room with natural light. The Xbox 360® was used with Kinect motion sensor technology.
The games were chosen according to the activities indicated in the COPM as difficult to perform in the initial evaluation. These required training in upper-limb and lower-limb motor skills, motor coordination, and cognitive skills. A detailed description of the information for each game and its main effects are shown in the Figure 1.
The sessions began with the game “20,000 Leaks” to familiarize the participant with the video game interface. Each participant played two or three games for 10 minutes each. In order to avoid fatigue, if necessary, a two-minute interval between games took place.